Although the world of cosmetic medicine has a glamorous, upscale image, the reality is harsher, even with relatively simple treatments such as injections of Botox or filler. Many patients lack the economic and emotional stamina to stick to a schedule of return visits to the doctor's office.

As a result, the next step in skin injections could come from the fast-growing world of so-called "permanent" fillers, which promise to smooth the skin for years - not just months - at a time.

At the typical doctor's office or med-spa that injects Botox, more than 40 percent of patients don't return for a second round of injections, and two out of three don't make it back for a third.

"The average is 2.3 visits before they abandon you," says Martin Braun, a Vancouver physician who spoke earlier this year at the Aesthetic Show in Las Vegas.

Inconvenience, pain and price play a role. Even simple cosmetic procedures, such as injections of Botox and dermal fillers, end up costing thousands of dollars, taking into account repeat visits. A patient who wants to remain wrinkle-free must return for new injections within about three to six months, once the effects of Botox wear off and dermal fillers are absorbed into the body.

Other patients opt for new, longer-lived fillers, which cost less in the long run, but can create long-term problems if the injections go awry.

"Patients with lots of wrinkles are shocked when they hear the price they have to invest for a treatment with hyaluronic acid (filler) every six months," says Said Hilton, president of the Academy for Cosmetic Medicine in Germany.

"They are very easily seduced to choose a permanent solution for the problems."

ARTEFILL

For example, the plastic-based filler Artefill from Artes Medical of San Diego, Calif., lasts five years. That might cost $1,500 to $2,500-plus, but over the same period would cost less than Restylane or Juvederm injections every six months at $600 to $1,200 per syringe.

But the rise of permanent fillers isn't just about money. Other physicians point to "the hassle factor," and the fear of injections, as reasons why patients are seeking long-term wrinkle solutions.

"A lot of patients come in and ask for permanent fillers, but I'm reluctant," says Newport Beach, Calif., dermatologist Dore Gilbert. "If something goes wrong with that filler, then you have a very difficult situation to deal with. You're trying to remove something that's permanent."

Fillers can sometimes form nodules under the skin. "If they're permanent," Gilbert said, "they're very hard to get rid of."

Mark Rubin, M.D., an assistant professor of dermatology at UC-San Diego, added: "A scary part is that, if you look in the literature, every single injectable material that's out there has (produced lumps in the skin). There's nothing you can use that is completely safe."

Although he's a shareholder in Artes Medical, Rubin views Artefill as a "niche product."

"It is never going to be the primary filler in my practice," he says.

RADIESSE

The filler Radiesse is made of synthetic calcium hydroxyapatite, a component of bones. It lasts about 12 months after it's injected.

"It's like injecting bone into the skin," said Gilbert, who favors shorter-lived fillers such as Restylane and Juvederm.

"Fillers that last four to eight months work the best and have the best safety profile," he said.